lecture 8 nutrition enteral and parenteral

8/12/2019 Lecture 8 Nutrition Enteral and Parenteral

1/42

The principles of feeding for infants

with normal and complicated delivery

Kardana, I Made

Division of Neonatology

Sanglah Hospital, Denpasar


2/42

TERM HEALTHY INFANTS

Rapidly adapt from relatively constantintrauterine supply

Should be breast-fed as soon as possiblewithin the first hour


3/42

Preterm infants

Are at increased risk of potentialnutritional compromise

Unable to feed and has a GI system less

ready to receive enteral nutrition


4/42

Imaturityorgan

Increaseddiseases

andanomaly

Increase

nutrient

demands

Nutrition problems of preterm

Limitednutrientreserve

RapidGrowth rate


5/42

ENTERAL NUTRITION


6/42

Infant > 1500 g

Usually > 32 weeks gestation

First feed 1-3 hours of age, 3 hourly feed

Total volume 60 ml/kg/day (first day), iftolerated volume is increased 30 ml/kg/day up

to a maximum of 160-180 ml/kg/day

Feeds orogastric / nasogastric tube


7/42

34-36 weeks gestation

show signs of sucking, swallowing

reflexes early introduction to the

breast-feeds

Early feeding may allow the release ofenteric hormones with exert a trophic

effect on GI system


8/42

Infant < 1500 g

Less able to adapt

Less well tolerate volumes of feed

Incomplete digestive and absorptive capacities

Slower gastric and gut emptying times

nutritional requirements More complex in infants < 1000 g


9/42

When to feed??

Depend on the infants condition

- Stable CV and respiratory status

- Evidence of gut function

- Take several days to achieve stability

iv dextrose should be initiated

PN if feed not within 3 days


10/42

How to feed???

Infant 1-1.5 kg 2 hourly feed,

intermittent orogastric/nasogastric

Infant < 1 kg hourly feed or by

continuous drip


11/42

How much to feed??

First day 60 ml/kg/day

Daily volume increased 20 or 30ml/kg/day

Eventual feed volume 180 ml/kg/day

two weeks to achieve depend ondegree of tolerance


12/42Type of feeding EBM is the best


13/42

EBM advantages

1. Provides species-specific nutrients to supportnormal infant growth

2. Gastrointestinal

GIT growth factors

Oligopeptides promote motility

Protection against NEC

3. Host defence / immunity

Against infection, Decrease in atopy


14/42

EBM advantages4. Developmental outcome

Higher score on developmental testing

5. Psychological benefit for mother and baby


15/42

Alternative (artificial) feeds

Standard formula

Preterm formula

Banked human expressed milk

Special feed : soy formula, elementalformula


16/42

Fluid management

First few days :

Loss of water

BW 5-10% in term infant and 15-20%

in very preterm infant

Water losses : IWL , Urine , abnormal loss


17/42

f lu id management

Days of

life

1 2 3 4 5+

Ml/kg/day 60 90 120 150 150+

Guidelines for water requirement


18/42

fluid management

Sick babies no need to increased fluid

requirement at this rate as long as there

are :

No sign of dehydration

Normal serum sodium

Normal glucose


19/42

PARENTERAL NUTRITION


20/42

Containdications to enteral feeding

Impending or recent extubation

Respiratory distress

Metabolic acidosis

Hypotension and shock, use of IV inotropes Pre and postoperatively

Serious infections, especially if paralitic ileussuspected

NEC Severe asphyxia

Before and after exchange transfusion


21/42

Parenteral nutrition (PN)

Prevent protein catabolism

Promote positive nitrogen balance Improve growth

Prevent essential nutrient deficiencies


22/42

parenteral nutrition

Expensive

Complicated Serious complication


23/42

Indication PN

Infants with BW < 1,500 g, in conjunctionwith slowly advancing enteral nutrition

Infants with BW > 1,500 g for whomsignificant enteral intake is not expectedfor > 3 days


24/42

indication PN

Post severe asphyxia

Severe respiratory disease Necrotizing enterocolitis

Major GI anomalies

Major surgery

Instability cardiovascular


25/42

Composition of PN

Carbohydrates (glucose)

Proteins (amino acids)

Fats/lipids

Vitamins

Trace elementsElectrolytes


26/42

parenteral nutrition glucose

First day 4 6 mg/kg/min of glucose

10% glucose and 60 ml/kg/day provide

4.2 mg/kg/min glucose

Glucose higher rates

by the fluid infusion rate by the glucose concentration


27/42

Glucose utilization rate

(mg/kg/min)

= rate (ml/h) x % dextrose

Wt (kg) x 6


28/42

parenteralnutr i t ion protein

1 g protein = 4 Kcal

Promotes weight gain

Positive nitrogen balance

Start at 1 g/kg/day, advance by

0.5 g/kg/day maximum 2.5 g/kg/day


29/42

Start at 1 g/kg/day, advance by 1

g/kg/day maximum 3 g/kg/day

Monitoring lipid tolerance

- Serum triglyceride levels < 150 mg/dl

parenteral nutritionl ipid


30/42

Electrolytes

Sodium

2-3 mmol/kg/day

Normal concentration 135-145mmol/L

First few days :

- relative haemoconcentration

- sodium does not need to be added


31/42

Electrolytes

Potassium

2-3 mmol/kg/day

Added when renal function and urineoutput normal

Normal concentration :

- 3.5 5 mmol/L (venous blood)

- 4 - 6 mmol/L (capillary blood)


32/42

Calcium

Requirement 1-2 mmol/kg/day

Hypocalcaemia preterm, SGA, sick infant,

diabetic mother

Normal concentration : 2.25 2.75 mmol/L

Sick infant 2 ml of 10% calcium

gluconate/100 ml iv fluid prevent

hypocalcaemia


33/42

Route of administration PN

Peripheral veins :

Less expensive,

fewer complication,

limited number of veins,

maximum glucose concentration 12.5%


34/42

Central veins

Long term infusion

Hypertonic solution

Maximum concentration 20-25%

Expensive

More complication


35/42

Monitoring parenteral nutrition

Test FrequencyGlycosuria Twice daily

Blood glucose Daily (more often in the first daysof life, or with glycosuria)

Sodium, potassium, acid-based Daily initially, then 3 times perweek

Calcium, magnesium 3 times per week

Urea, creatinine 2 times per week

Platelet count 2 times per weekBilirubin Daily, or more often, if jaundiced

Liver function test If billrubin substantiallyconjugated

Triglyceride Daily if using intralipid


36/42

Complications PN

Glucose hyperglycaemia, glycosuria, osmoticdehydration, thrombophlebitis

Amino acid blood urea , hyperammonaemia,

liver cell damage, metabolic acidosis Intralipid reduced platelet adhesiveness,

diminished pulmonary blood flow, liver cell

damage, and competition with bilirubin foralbumin binding sites.


37/42

complications

Of the infusion equipment

Systemic infection Thrombosis

Hemorrhage

Dislodgement with extravasations


38/42

Assessing nutritional adequacy

Anthropometric measurements

To compare growth rate with approximate

intrauterine growth rate standards

Expected mean weight gain

2-4 weeks1-2 kg BW : Gain 12-15 g/kg/d, 10-14 days

> 2 kg BW : Gain 8-12 g/kg/d, 7-10 days


39/42

assess ing nu tr it ional

adequacy

Clinical tolerance

Vomiting

Excessive residual

Marked abdominal distention

Diarrhea

NEC

i i i l


40/42

assessing nutritional

adequacy

Indications of inappropriate nutrition

- Poor growth energy intake >

- ALP , Ca & P , Ca & P intake

vitamin D deficiency

- Tryglyceride level fat intolerance

- Bilirubin, ALP, transaminase cholestasis


41/42


42/42

lecture 8 nutrition enteral and parenteral

Documents